News From ACFAS

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Come fiesta with us on the banks of the River Walk in San Antonio during ACFAS 2020, February 19–22, 2020 at the newly expanded Henry B. Gonzalez Convention Center. Experience brand-new clinical sessions and workshops, exciting special events and state-of-the-art exhibits as you take in this extraordinary city’s rich heritage.

From Spanish colonial missions and historic landmarks to a thriving art community and authentic Tex-Mex cuisine, San Antonio lets you step back in time while fully embracing the present.

We are using your input from the ACFAS 2019 evaluations to develop dynamic programming for ACFAS 2020, and we cannot wait to show you what we have in store!

Mark your calendar now, and keep an eye on ACFAS publications and acfas.org for ACFAS 2020 details as they become available. Spots still remain in our August, October and November Arthroscopy of the Foot and Ankle courses! Register now and experience the unique learning environment of the Orthopaedic Learning Center in Rosemont, Illinois.

ACFAS thought leaders will host didactic and hands-on laboratory learning in this interactive course designed for DPMs of all skill levels. Enjoy more than nine hours of lab time plus the opportunity to rotate to four different brands of scope to refine your arthroscopic technique.

A debriefing and case discussion the first night of the course will allow you to share and discuss your own arthroscopic radiographs.

Arthroscopy of the Foot and Ankle fulfills privileging requirements and is worth 16 continuing education contact hours. This is the real deal—secure your spot now at acfas.org/skills! Congratulations to Grant Yonemoto and Throy Austero, the 2019 Mirmiran Family Scholars and members of NYCPM Class of 2020!

The family of Roya Mirmiran, DPM, FACFAS, based in Sacramento, California, provides scholarships every year to top students who are hand-selected to attend the ACFAS Annual Scientific Conference. Grant and Throy received funds to offset their cost of attending ACFAS 2019 in New Orleans in February.

The Mirmiran Scholarship opportunity rotates to a different campus every year. For 2020, students from CSPM will be recognized.
Big West Region:
AZPod: Ross Groeschl, Class of 2021

Great Lakes Region:
Kent State: Deana Lewis, Class of 2021

Midwest Region:
DMU: Joseph Brown, Class of 2021
Scholl: Ambreen Sharif, Class of 2021

Northeast Region:
NYCPM: Rahim Lakhani, Class of 2020

Pacific Region:
CSPM: Christopher Zimmer, Class of 2021
Western U: Jordan Richardson, Class of 2021

Southeast Region:
Barry: Justin Carney, Class of 2021

Tri-State Region:
Temple: Samuel Straus, Class of 2021

Foot and Ankle Surgery

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A study evaluated whether the type of stabilization after ankle arthrodesis will affect the functional outcome in Foot and Ankle Ability Measure (FAAM) scale, pain level, period of hospitalization and rate of complications. Forty-seven individuals were reviewed after ankle arthrodesis with Ilizarov fixation and internal stabilization between 2007 and 2015. Total complications in the Ilizarov group was 13, corresponding to 0.62 average complications per patient. The internal stabilization group had 15 complications, which corresponded to 0.58 complications per patient on average.

The intergroup difference in rate of complications was statistically insignificant, and the mean VAS pain level before treatment in the Ilizarov group was 4.69 before treatment and 1.5 after treatment. The internal stabilization cohort had a mean VAS pain level of 4.71 before treatment and 2.9 after treatment. The mean period of hospitalization in the Ilizarov group was 5.29 days, versus 5.71 days for the internal stabilization cohort. The mean functional outcome in FAAM scale was 79.38 for the Ilizarov group, compared to 70.11 for the internal stabilization group.


A study sought to assess the intraoperative realization of computer-assisted preoperative planning (CAPP) and clinical outcomes based on computer-assisted virtual surgical technology for calcaneal malunions. Twenty patients with 21 calcaneal fracture malunions operatively treated with the help of CAPP were retrospectively reviewed between 2010 and 2016, with the average follow-up time of 22.3 months. Average time required for CAPP was 41.8 minutes.

All surgical processes were performed to CAPP requirements, and six patients were treated with joint-preserving osteotomy. Fourteen underwent subtalar distraction bone block arthrodesis, among which the medial displacement calcaneal osteotomy was additionally performed in six patients. The average American Orthopaedic Foot and Ankle Society, SF-36 physical component summary and VAS pain scores improved to 77.4, 64.3 and 1.4, respectively, at final follow-up. The postoperative calcaneal morphological parameters and the range of motion of ankle had significant restoration.


A retrospective review of the radiographic outcomes of retained hardware after pen reduction internal fixation (ORIF) of tarsometatarsal joint (TMTJ) fractures/dislocations in 61 patients was conducted. The average age at the time of operation was 37.3 plus or minus 14.9 years. ORIF was carried out with 3.5 fully threaded cortical screws. Assessment of clinical and radiographic results was performed at two weeks, six weeks, three months, six months and 12 months post-surgery.

Out of the 61 patients included in the study, only two demographic variables exhibited a trend for an adverse outcome. Older age correlated with lost reduction, and elevated body mass index correlated with hardware failure. Diabetes was correlated with an increased risk of postoperative infection, but not hardware failure. During follow-up, 49 patients lacked failure of fixation.

Practice Management

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Experts recommend six tips to ensure physicians are deservedly paid for CPT modifiers without risking compliance hazards, including having familiarity with payer policies. Hiring a certified coder is another recommendation, as is concentrating on clinical documentation. Physicians should also examine their billing system more closely, making sure the vendor incorporates National Correct Coding Initiative (NCCI) edits and updates them quarterly.

Also advised is for physicians to append each modifier to the correct code, referring to the NCCI procedure-to-procedure edits or specific payer bundling rules when settling on what procedure or service code should include this modifier. Finally, physicians should plan contingencies for payment problems, including balance billing the patient, fighting denials and negotiating payer contracts.


Physician practices can stay on top of their revenue by making patients aware of their billing and collection policies from the start. Experts recommend calling patients before appointments to discuss preauthorization and benefits and communicating billing policies when they come for their first visit. Certain offices have patients sign a form saying they understand and agree to billing practices.

Having patients digitally sign payment agreements on tablets, with copies sent to their email, adds transparency and accountability and eases registration. Front desk staff should also be trained in the fundamentals of billing procedures and insurance.


The Agency for Healthcare Research and Quality (AHRQ) has unveiled QuestionBuilder, an app intended to help patients prepare questions for their next physician appointment. The app seeks to helps patients make the conversation between the patient and doctor more productive. AHRQ Director Gopal Khanna says QuestionBuilder has an easy-to-use interface and replaces a tool previously developed by AHRQ that was available in paper and web-based formats. The app requires users to enter the time and place of an upcoming appointment and issues prompts to formulate appropriate questions.


A new American Well survey found 22 percent of physicians have used telehealth to see patients, a 340 percent jump from 2015 to 2018, while electronic health record adoption among office-based physicians only increased by 68 percent from 2003 to 2006. Moreover, 69 percent of physicians said they would be willing to use telehealth, a 12-percentage-point gain from 2015. Top reasons for telehealth usage include better patient access to care, more efficient use of time, reduced healthcare costs, high-quality communications with patients and an enhanced doctor-patient relationship.

The survey also found physicians expressing the strongest interest in telehealth are the least likely to have used it, correlating with high rates of burnout. Obstructions to telehealth adoption include uncertainty about reimbursement, issues of clinical appropriateness, lack of physician buy-in and poor leadership support.

Health Policy and Reimbursement

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Patients with high-deductible health insurance plans will opt to delay care or avoid treatment altogether, according to recent studies. Dr. Veena Shankaran of the Hutchinson Cancer Research Center, says, "High-deductible plans are really the epitome of the access-to-care problem. People don't have the liquid cash to meet their deductible, so you see delays in care or even avoiding treatment altogether." A recent Health Affairs study found that women whose employers switched insurance coverage from low-deductible health plans (i.e., deductibles of $500 or less) to high-deductible health plans (i.e., deductibles of $1,000 or more) between 2004 and 2014 often delayed care, regardless of their income. In some cases, delays of that length might lead to poorer health outcomes, says J. Frank Wharam, an internist and specialist in insurance and population health, who led the study.


The Medicaid and CHIP Payment and Access Commission (MACPAC) is recommending Congress eliminate the cap on drug rebates paid to state Medicaid programs. MACPAC, the nonpartisan committee that advised Congress on Medicaid, says the savings from higher rebates would allow states to provide the same level of drug coverage at lower costs and continue to exert downward pressure on price increases. The Congressional Budget Office (CBO) estimates that if enacted, the change could save the federal government between $15 billion and $20 billion over 10 years. MACPAC is also calling on Congress to allow states to restrict coverage of new drugs or new drug formulations for up to 180 days after they have been approved by FDA. CBO estimates that would result in federal savings of less than $25 million over 10 years.


Washington Gov. Jay Inslee signed a measure to ensure that some of the Affordable Care Act's (ACA) federal protections are protected in state law. The measure prevents insurers from blocking patients with preexisting conditions from purchasing their plans, and it cannot retroactively deny coverage except for fraud or misrepresentation. The bill includes other federal protections, including yearly out-of-pocket maximums and a list of must-cover health benefits. Inslee and Washington state Insurance Commissioner Mike Kreidler note that the new law would not offer full protection if the ACA is repealed since Medicaid expansion and low-income subsidies would be eliminated.

Medicine, Drugs and Devices

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A series of three papers appearing in The Lancet demonstrate how efforts to alleviate postoperative pain have fed the opioid epidemic. Opioids are the go-to standard for improving patient comfort after an operation, and use of opioid analgesics has grown significantly—including for minor procedures. In addition, there has been a trend of overprescribing after surgery. While prolonged use can predispose some patients to long-term abuse themselves, leftover doses can also be diverted and used by people other than the patients for whom the prescriptions were written.

The authors offer suggestions for mitigating these risks, including specialist transitional pain clinics, drug take-back programs or other opioid disposal options for patients, and nonopioid and opioid-sparing pain management alternatives. They also believe further study is needed to address opioid tolerance and opioid-induced hyperalgesia and that clinical guidelines should provide consensus and clarity on postoperative opioid prescribing. "Over the past decade, there has been an increasing reliance on strong opioids to treat acute and chronic pain, which has been associated with a rising epidemic of prescription opioid misuse, abuse and overdose-related deaths," says Prof. Paul Myles of Australia's Monash University, who took the lead on the series. "To reduce the increased risk of opioid misuse for surgery patients, we call for a comprehensive approach to reduce opioid prescriptions, increase use of alternative medications, reduce leftover opioids in the home and educate patients and clinicians about the risks and benefits of opioids."


Amgen has set the U.S. list price for its new romosozumab-aqqg (Evenity) osteoporosis drug at $1,825 a month, or $21,900 for a full 12-month course of injections. The U.S. Food and Drug Administration (FDA) last week approved the bone-building drug for postmenopausal women who are at high risk of fracture but required the label to have a boxed warning, flagging increased risk of heart attack, stroke and cardiovascular-related death. The drug, part of a new class of drugs known as sclerostin inhibitors, was studied in large clinical trials for one year, and FDA said its use should be limited to one year. "We priced this product so that it is clearly a better value than existing agents that build bone," said Murdo Gordon, executive vice president of global commercial operations at Amgen. The drug is designed to reduce the risk of fracture by increasing bone mass and mildly inhibiting the breakdown of bone minerals.


Gov. Gavin Newsom of California said Los Angeles County will join the collective drug-purchasing system that he is developing for state agencies. On the day he took office, Newsom signed an executive order to create a single purchaser of prescription drugs by 2021 for the 13 million individuals covered by Medi-Cal and other agencies that purchase drugs for state employees, retirees, hospitals and inmates. He urged local governments and private companies to participate in the system, which he said would give them more leverage to negotiate lower prices for medicines. Los Angeles County spends almost $250 million annually on prescriptions just at its public hospitals and clinics. According to Janice Hahn, chair of the county Board of Supervisors, Los Angeles and the state would be "more effective when we work together." Newsom said he has discussed his plan with other governors as well.